Food-borne Illness Complaint Submission – Western UP Health Department

Instructions:

Please complete all fields of this form. A sanitarian will contact you for additional information within 1 business day.

Complaint Received From: *

First

Last

Address *

Address Line 1

City

State

Zip Code

Phone *

Additional Contact Information

Person to Contact for More Information: *

First

Last

Address same as above

Address

Address Line 1

City

State

Zip Code

Daytime Phone:

Evening Phone:

Complaint Details

Please tell us about your complaint: *

Date & Time Suspect food consumed:

Date

Time

Is anyone Ill?

Yes
No

Number of people Ill:

Does everyone live in the same household?

Yes
No

When did the illness begin? *

Date

Time

Predominant Symptoms: *

Is this complaint related to a meal at a restaurant? *

Yes
No

Suspect Meal: *

Restaurant Name: *

Address of Restaurant

Address Line 1

City

State

Suspect Food(s) Eaten: *

Source of Suspect Food: *

Brand of Food:

Lot Number, if known:

Additional People Attending Suspect Meal:

If additional people outside of your household attended the same meal, please provide their name and contact information below:

Attendee 1

First

Last

Phone

Attendee 2

First

Last

Phone

Attendee 3

First

Last

Phone

Attendee 4

First

Last

Phone